Provider Demographics
NPI:1972775427
Name:PETTIT, ELVY JR (PA)
Entity type:Individual
Prefix:
First Name:ELVY
Middle Name:
Last Name:PETTIT
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3080 TRENWEST DR
Mailing Address - Street 2:THE SALEM CENTER
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3208
Mailing Address - Country:US
Mailing Address - Phone:336-768-0496
Mailing Address - Fax:336-768-0498
Practice Address - Street 1:3080 TRENWEST DR
Practice Address - Street 2:THE SALEM CENTER
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3208
Practice Address - Country:US
Practice Address - Phone:336-768-0496
Practice Address - Fax:336-768-0498
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC101961363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
C81057Medicare UPIN